India follows the World Health Organisation (WHO) approved five-dose rabies vaccine protocol with immunoglobulin in category III bites.
Published May 10, 2025 | 7:00 AM ⚊ Updated May 24, 2025 | 7:49 PM
Rabies vaccination. (iStock)
Synopsis: Recently, three children died in Kerala due to rabies infection despite receiving vaccination. Doctors say if bites or scratches are on high-risk zones, the virus has less ground to cover, and it can reach the central nervous system in a matter of days.
“I followed all protocol, washed the wound, got her the vaccine, still, she died,” said the mother of seven-year-old Niya Faisal, who recently died due to rabies infection after being bitten by a dog in Kerala.
Thirteen-year-old Bhagyalakshmi from Palakkad and five-year-old Ziya Faris from Malappuram also met the same fate — vaccinated, treated, and still gone. The government insists the vaccines are effective.
However, if everything was done by the book, why are children still dying? Public health activists say this isn’t just a failure of administration — it may be time to ask if the book itself is flawed. Does India’s rabies protocol, unchanged for decades, need a fundamental rethink?
India follows the World Health Organisation (WHO) approved five-dose rabies vaccine protocol with immunoglobulin in category III bites.
Dr Rajeev Jayadevan, convenor of the Indian Medical Association (IMA) research cell and a public educator, who’s been following the cases of dog bite-related deaths in Kerala very closely, told South First, “India’s prevention protocol is well laid out and in line with WHO’s recommendations.”
Echoing the same, Dr NR Ramesh Masthi, professor and Head of the Department (HoD) of Community Medicine at Kempegowda Institute of Medical Sciences (KIMS), Bengaluru, said, “We have a robust programme. The National Action Plan for Rabies Elimination by 2030 (NAPRE) is being implemented in the country. Efficacy of vaccine is also very good.”
Doctors stressed that it was not right to question the efficacy of the vaccine, as that might lead to people not trusting the vaccine and might create problems, including people not coming forward to take the vaccine.
However, the question arises whether the protocol or programme is built on a system which assumes ideal conditions like: Prompt wound washing, cold chain preservation and trained professionals infiltrating the wound. How often do these “ideal conditions” play out in real life — especially in a Primary Health Centre (PHC) in rural Kerala, Tamil Nadu, Karnataka or any other state like Jharkhand?
“Rabies prevention today is algorithmic, but rabies as a virus is not. It’s a bullet train to the brain in some cases,” said Dr Vijayalakshmi N, infectious disease expert from Chennai.
Agreeing that the main challenge lies with the treatment of dog bites and cat scratches, Dr Jayadevan explained, “There exists a need for increased public awareness regarding the need for immediate first-aid following animal bites.”
He said, “When a bite occurs, the animal’s saliva, containing numerous viruses, enters the wound. The best chance to eliminate these viruses is to immediately wash the wound with running water and soap for at least 15 minutes, which will destroy this particular type of virus.”
“Thus, very few viruses will remain behind for the vaccine to tackle. Unfortunately, in many instances, victims are taken to the hospital by bystanders without providing adequate first aid, assuming that the hospital will provide first aid. This window is critical,” he added.
“The lack of first aid could aid the virus to be able to get through into the nervous system of the patient and reach the brain, a process which will take several days or maybe weeks. The best chance to stop the virus is before it gains entry into the nerves,” Dr Jayadevan elaborated.
“Washing has been underestimated, and this should be the single focus of public education. Do not leave first aid to health workers,” he stressed and added: “Do it at the spot, as soon as possible after the bite occurs.”
According to a study published by The Lancet in 2022, “Unfortunately, only 38 percent of bite victims washed their wounds with soap and water, despite WHO guidelines recommending 15 minutes of flushing with virucides.”
In all three recent deaths in Kerala — Niya Faisal, Bhagyalakshmi, and Ziya Faris — the bite location was either the head, neck, or upper limbs. These are high-risk zones. The virus has less ground to cover, and it can reach the central nervous system in a matter of days.
Experts question why India follows a one-size-fits-all protocol, while countries like Thailand, Philippines, and even pockets in Vietnam are already piloting site-based escalation of therapy, where patients with head or face bites are hospitalised and monitored — not sent home after a vaccine shot with a card.
Dr Rajeev said the problem with children is that they are small, short and are often targeted by dogs because they move quickly and appear easier to attack than their adult counterparts. For a rabid dog, it is common to cause severe wounds on small children, especially over the face, neck and fingertips, which are rich in nerve supply.
“When bites occur in such areas, the bite has a greater chance of entering the nervous system earlier than in other areas. Thus, in rare cases, rabies infection occurs even after properly administering treatment, mostly in children who have had such deep wounds in high-risk areas. This has been the case in the rabies deaths that have occurred in Kerala recently,” he explained.
Dr Rajeev said the public needs to understand that high-risk bites are at higher risk for rabies infection and need immediate first aid as well as treatment protocol. “Any delay in administering first aid or specific therapies will increase the risk of rabies in the patient,” he said.
Studies have shown that around 5,700 to 20,000 cases of rabies are recorded in India every year. However, exact rates are unknown. Dr Rajeev added that the majority of rabies deaths worldwide occur due to a lack of access to healthcare systems, availability of vaccine serums or hesitancy to take these medications.
“These barriers need to be overcome with sustained education,” he added.
However, Dr Rajeev added, “The treatment protocol, including vaccines and immunoglobulin, is tailored to the severity of the exposure. The dosages, wound infiltration methods and time infiltration methods are indeed current and in line with the recommendations of the WHO.”
In India, the rabies vaccine, consisting of an inactivated virus, is administered intradermally — a needle is gently introduced into the top layer of the skin, producing a blood-like wheal which might look like a mosquito bite.
Dr Rajeev, explaining how the vaccine works, said, “This activates the immune system because of the presence of antigen-presenting cells in this particular layer of the skin. Once the cells are activated, the immune system goes to work and a strong immune response, including antibodies, is produced within a week. This destroys the viruses before they get a chance to reach the brain. Once the virus enters the brain or spinal cord, no treatment is found to be effective.”
Explaining further about the challenges, he said, “The intradermal injection can be technically challenging when dealing with children who are anxious, crying, agitated and possibly restless during the time of injecting the vaccine.”
The needle needs to be carefully introduced into the top layer of the skin by experienced personnel. This type of injection is different from other injections like subcutaneous (insulin injection) and Intramuscular (Covid vaccine). Among the three types of vaccines, intradermal is the most challenging type of vaccine to administer. However, trained staff are experienced in administering these injections.
Dr Masti said, “The head and face are innervated with lots of nerves and are at high risk. Generally, treating physicians ensure the entire wound is infiltrated after a thorough wound wash.”
However, a senior health official from Karnataka questioned the availability of experienced personnel in PHCs for the immediate administration of these vaccines.
He said, “In namma clinics of Karnataka, for instance, dog bite cases are immediately referred to nearby PHCs. Though they may not be far away, the cleaning protocol is not followed most of the time. Delay in administering the vaccine or the unavailability of personnel to administer it, especially in rural areas, might be risky. A protocol for the immediate admission of such patients and classification as high-risk cases should be firmly instilled not only in the public but also among healthcare workers,” he added.
Kerala Health Minister Veena George said the vaccines were WHO-prequalified. However, the state’s procurement is often driven by the lowest-cost bidding.. Rabies vaccines in India are made by both private and public-sector units, but batch-wise efficacy, immunogenicity, and sterility test results are rarely made public.
In fact, a 2022 audit by the Comptroller and Auditor General (CAG) flagged serious gaps in vaccine quality testing and tracking in Maharashtra and Tamil Nadu. Also, in the same year, it was noted that the Kerala government procured a batch of Equine Rabies Immune Globulin (ERIG) vaccines that had not undergone the mandatory safety tests.
A study published in The Lancet mentioned: “Due to severe shortage of vaccines resulting from an increase in rabies cases, 250 anti-rabies vaccines were allegedly administered without being subjected to the required quality tests.”
Reportedly, the first 16,000 vials — sent to Kerala Medical Services Corporation Limited (KMSCL) warehouses in Thiruvananthapuram, Ernakulam, and Kozhikode — lacked final approval from the Central Drug Laboratory (CDL) and were observed by the manufacturer for only seven days instead of the required 14 days.
Despite this, the KMSCL distributed the vaccines immediately, citing an acute shortage. The supplier had warned that KMSCL alone would bear responsibility for any adverse effects. The state health minister’s office stated that urgent procurement was instructed, leaving protocol decisions to KSMCL.
However, the State Drugs Controller noted that the vaccines should not have been supplied without CDL clearance.
An official from Kerala Health Department said that the total order then was for 1.4 lakh vials, with 60,500 to be distributed in the first phase. Alarmingly, vaccine payment was conditional on the CDL report, but the distribution was not. This unusual relaxation of tender norms, combined with a delay in placing the order — only on 6 June instead of March — meant there was no time for proper quality checks.
However, appreciating the protocol process in Karnataka, a health department official explained that the procurement and distribution of rabies vaccines are managed by the Karnataka State Drugs Logistics and Warehousing Society (KSDLWS). This agency is responsible for acquiring Anti-Rabies Vaccines (ARV) and Rabies Immunoglobulin (RIG) through public e-tendering processes, ensuring that all government hospitals maintain adequate stocks. The procurement is based on annual consumption data, with an additional buffer stock to prevent shortages.
Recognising the fatal nature of rabies and the importance of timely treatment, the Karnataka Health Department has mandated that all government hospitals provide ARV and RIG free of cost to all animal bite victims, regardless of their economic status. This directive aims to eliminate financial barriers to accessing the life-saving treatment.
Dr Rajeev said vaccines and serums are to be stored at a temperature between two and eight degrees Celsius, which is basically the same temperature as an ordinary refrigerator of around four degrees Celsius. These are stored in specialised refrigerators meant only for vaccine storage. They should also have power backups so that, in case of an electricity failure, the vaccines maintain their temperature.
Maintaining this temperature is also referred to as the cold chain, which basically means that from the factory that manufactured the vaccine to the patient who received it, the temperature should remain the same.
Studies from neighbouring countries have shown that in remote regions where electricity was frequently unavailable and there was no power backup, vaccines stored in such conditions were found to be ineffective. Therefore, storage conditions need to be carefully monitored to prevent loss of effectiveness. However, there are no indications to show that storage conditions in India are inadequate.”
Dr Maasti said Karnataka has a robust storage system and the state uses the same cold chain utilised for routine immunisation. However, experts added that sometimes there may be delays in procurement due to various reasons, including the unavailability of vaccines.
Health department officials said that presently, there is enough stock, and these vaccines are available at all PHCs and government hospitals.
A paper published by The Lancet argued that Preexposure prophylaxis (PrEP) should be advocated for high-risk populations and children having less access to PrEP, and where the incidence of dog bite is greater than five percent. PrEP is the use of medication to prevent the spread of a disease before exposure to it.
The authors argued that, considering the increase in animal bite cases and rabies deaths, Kerala should consider using PrEP. “Cross-state sharing of vaccines and RIG during the crisis period should be adopted. The availability of critical supplies should be displayed on e-portals such as e-Raktkosh in various hospitals in every region,” the authors argued.
It can be noted that the Kerala Government Medical Officers’ Association (KGMOA) on Tuesday, 7 May, urged the state government to launch a universal preexposure rabies vaccination programme, especially for children and other high-risk groups.
In a statement issued, the association highlighted that rabies is almost always fatal once symptoms occur. “Children make up nearly 40 percent of the victims, and in Kerala, about 20-25 people still die from rabies each year,” the association said.
It noted that the WHO recommends a simple three-dose intradermal vaccination (on days 0,7, and 21/28) for pre-exposure protection.
The association explained: “This vaccine provides long-term immunity. If someone who has had these vaccines is later bitten, they only need two booster doses, and not the costly and hard-to-find rabies immunoglobulin,”
It also called on the government to start awareness programmes for children. It said, “If a full state-wide rollout is not immediately happening, then the plan should begin in high-risk areas and gradually expand.”
(Edited by Muhammed Fazil.)
